Posted and filed under Fraud, FWA, Healthcare.

Retired OIG Special Agent and Advize’s Director of Litigation & FWA Support will be stepping in each week to examine current fraud trends from the lens of an investigator. Stay tuned for weekly insights, updates, and information on healthcare’s most expensive crimes.

As some of you who follow healthcare fraud have likely read, the CEO of a large-scale telemedicine fraud ring pleaded guilty in the District of New Jersey to healthcare fraud and kickbacks.  The fraud, over $200 million, was investigated by not only my former agency, but the field office that I called home most of my career.  Without going into the details of the case, it came to mind that many who do not understand the criminal process, and more importantly, the investigative process, will ask “what about all the others who were involved?”

It is a common question to inquire as to what happens to all the “bad guys” who are implicated, one way or another, in an investigation.  Those who investigate any type of crime will often find there are many individuals involved in the crime.  Unfortunately, that does not always lead to everyone being charged. If I was able to obtain a criminal charge against every person who I encounter, who technically violated a federal law, I would have been busier than a one-armed man in a waving contest.  There are thresholds that the US Attorney’s Office must consider in making decisions to prosecute.  There are office priorities, and shifting resources to consider. Everyone lies to federal agents, and yes, it’s a crime to do so (as with everyone’s most famous reference, Martha Stewart-who only committed the violation of false statements).  Rarely are people ever actually prosecuted for it.

My long-winded point is that in the situation of the $200 million man, he will be the first of what will likely be many. By having the “bad guy” at the top plead guilty, it works to create a set of prosecutorial decisions that will work to obtain guilty pleas from many others involved in the fraud. Healthcare fraud investigations are extremely complex, and by securing the plea of the top individual in the scheme serves as a message to those below; the evidence is strong. Take this discussion to the next step; what if the top of the scheme is cooperating (and be certain, I do not know that).  If that is the case, does he have documents, emails, text messages, and/or audio recordings with others involved that were previously unknown to investigators?

It will be interesting to see how this plea and others unfold. Remember, the arrests that transpired on this matter occurred in April, and the plea in September.  That is lightning speed for a healthcare fraud investigation, even by Strike Force standards.  My time with Strike Force saw some fast turnaround on cases, but this was very fast.

Advize Health LLC is a healthcare advisory and consulting company that provides a breadth of healthcare industry services in the payer, provider, and legal communities. Contact Eric Rubenstein for more information on our Fraud Spotlight series.